Health Care Access and Utilization and the Latino Health Paradox

BACKGROUND

The Latino health paradox is the phenomenon whereby recent Latino immigrants have, on average, better health outcomes on some indicators than Latino immigrants who have lived in the United States longer and US-born Latinos and non-Latino Whites. This study examined whether the paradox holds after accounting for health care access and utilization.

METHODS

The 2019-2020 National Health Interview Survey data were used. The main predictors included population groups of foreign-born and US-born Latinos (Mexican or non-Mexican) versus US-born non-Latino Whites. Predicted probabilities of health outcomes (self-reported poor/fair health, overweight/obesity, hypertension, coronary heart disease, diabetes, cancer, and depression) were calculated and stratified by length of residence in the United States (<15 or ≥15 years) among foreign-born Latinos and sex (female or male). Multivariable analyses adjusted for having a usual source of care other than the emergency department, health insurance, a doctor visit in the past 12 months, predisposing and enabling factors, and survey year.

RESULTS

After adjusting for health care access, utilization, and predisposing and enabling factors, foreign-born Latinos, including those living in the United States ≥15 years, had lower predicted probabilities for most health outcomes than US-born non-Latino Whites, except overweight/obesity and diabetes. US-born Latinos had higher predicted probabilities of overweight/obesity and diabetes and a lower predicted probability of depression than US-born non-Latino Whites.

CONCLUSIONS

In this national survey, the Latino health paradox was observed after adjusting for health care access and utilization and predisposing and enabling factors, suggesting that, although these are important factors for good health, they do not necessarily explain the paradox.

Democratizing Native Hawaiian and Pacific Islander Data: Examining Community Accessibility of Data for Health and the Social Drivers of Health

Making data accessible to communities is essential for developing community-driven solutions to address health inequities. In this analytic essay, we highlight the importance of democratizing data for Native Hawaiians and Pacific Islanders (NHPIs)-diverse populations that historically have had little access to their data-in the context of achieving equity in health and the social drivers of health. We provide a framework for evaluating community accessibility of data, which includes concepts of data availability, salience, cost, and report back. We apply the framework to evaluate community accessibility of NHPI data from 29 federal data sources. In addition, we provide results from a survey of NHPI-serving community organizations in California conducted from December 2021 to February 2022 to assess community data needs. Findings reveal federal gaps in data accessibility, as well as NHPI community organizational needs for increased data accessibility, data saliency, and technical capacity. Furthermore, organization leads expressed concerns about data privacy, security, and misuse. We provide recommendations for data custodians to improve accessibility of timely, accurate, and robust data to support NHPI communities. (Am J Public Health. 2024;114(S1):S103-S111. https://doi.org/10.2105/AJPH.2023.307503).

Evolving academic and research partnerships in global health: a capacity-building partnership to assess primary healthcare in the Philippines

Building fair, equitable, and beneficial partnerships between institutions collaborating in research in low- and middle-income countries (LMIC) and high-income countries (HIC) has become an integral part of research capacity building in global health in recent years. In this paper, we offer an example of an academic collaboration between the University of California Los Angeles, Center for Health Policy and Research (UCLA CHPR) and the University of Philippines, Manila, College of Public Health (UPM CPH) that sought to build an equitable partnership between research institutions. The partnership was built on a project to build capacity for research and produce data for policy action for the prevention and care of non-communicable diseases (NCDs) through primary healthcare in the Philippines. The specific objectives of the project were to: (1) locally adapt the Primary Care Assessment Tool for the Philippines and use the adapted tool to measure facility-level primary care delivery, (2) conduct focus group discussions (FGDs) to gather qualitative observations regarding primary care readiness and capacity, and (3) conduct a comprehensive population-based health survey among adults on NCDs and prior healthcare experience. We describe here the progression of the partnership between these institutions to carry out the project and the elements that helped build a stronger connection between the institutions, such as mutual goal setting, cultural bridging, collaborative teams, and capacity building. This example, which can be used as a model depicting new directionality and opportunities for LMIC-HIC academic partnerships, was written based on the review of shared project documents, including study protocols, and written and oral communications with the project team members, including the primary investigators. The innovation of this partnership includes: LMIC-initiated project need identification, LMIC-based funding allocation, a capacity-building role of the HIC institution, and the expansion of scope through jointly offered courses on global health.

Association of neighborhood gentrification and residential moves with hypertension and diabetes control in Los Angeles County, 2014-2019: A retrospective cohort study

OBJECTIVE

To examine whether gentrification exposure is associated with future hypertension and diabetes control.

METHODS

Linking records from an integrated health care system to census-tract characteristics, we identified adults with hypertension and/or diabetes residing in stably low-SES census tracts in 2014 (n = 69,524). We tested associations of census tract gentrification occurring between 2015 and 2019 with participants' disease control in 2019. Secondary analyses considered the role of residential moves (possible displacement), race and ethnicity, and age.

RESULTS

Gentrification exposure was associated with improved odds of hypertension control (aOR: 1.08; 95% CI: 1.00, 1.17), especially among non-Hispanic Whites and adults >65 years. Gentrification was not associated with diabetes control overall, but control improved in the Hispanic subgroup. Disease control was similar regardless of residential moves in the overall sample, but disparate associations emerged in models stratified by race and ethnicity.

CONCLUSIONS

Residents of newly gentrifying neighborhoods may experience modestly improved odds of hypertension and/or diabetes control, but associations may differ across population subgroups.

POLICY IMPLICATIONS

Gentrification may support-or at least not harm-cardiometabolic health for some residents. City leaders and health systems could partner with impacted communities to ensure that neighborhood development meets the goals and health needs of all residents and does not exacerbate health disparities.

Undocumented Latino Immigrants and the Latino Health Paradox

INTRODUCTION

Despite having worse healthcare access and other social disadvantages, immigrants have, on average, better health outcomes than U.S.-born individuals. For Latino immigrants, this is known as the Latino health paradox. It is unknown whether this phenomenon applies to undocumented immigrants.

METHODS

This study used restricted California Health Interview Survey data from 2015 to 2020. Data were analyzed to test the relationships between citizenship/documentation status and physical and mental health among Latinos and U.S.-born Whites. Analyses were stratified by sex (male/female) and length of U.S. residence (<15 years/>= 15 years).

RESULTS

Undocumented Latino immigrants had lower predicted probabilities of reporting any health condition, asthma, and serious psychological distress and had a higher probability of overweight/obesity than U.S.-born Whites. Despite having a higher probability of overweight/obesity, undocumented Latino immigrants did not have probabilities of reporting diabetes, high blood pressure, or heart disease different from those of U.S.-born Whites after adjusting for having a usual source of care. Undocumented Latina women had a lower predicted probability of reporting any health condition and a higher predicted probability of overweight/obesity than U.S.-born White women. Undocumented Latino men had a lower predicted probability of reporting serious psychological distress than U.S.-born White men. There were no differences in outcomes when comparing shorter- with longer-duration undocumented Latino immigrants.

CONCLUSIONS

This study observed that the Latino health paradox may express patterns for undocumented Latino immigrants that are different from those for other Latino immigrant groups, emphasizing the importance of accounting for documentation status when conducting research on this population.

Association of Cost-Driven Residential Moves With Health-Related Outcomes Among California Renters

IMPORTANCE

Unaffordable housing is associated with adverse health-related outcomes, but little is known about the associations between moving due to unaffordable housing and health-related outcomes.

OBJECTIVE

To characterize the association of recent cost-driven residential moves with health-related outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study involved a weighted multivariable regression analysis of California Health Interview Survey data from January 1, 2011, to December 31, 2017. A population-based sample of 52 646 adult renters and other nonhomeowners in California were included. Data were analyzed from March 2, 2021, to January 6, 2023.

EXPOSURE

Cost-driven moves in the past 3 years relative to no move and to non-cost-driven moves.

MAIN OUTCOMES AND MEASURES

Five outcomes were assessed: psychological distress (low, moderate, or severe, as categorized by the 6-item Kessler Psychological Distress Scale), emergency department [ED] visits in the past year (any vs none), preventive care visits in the past year (any vs none), general health (poor or fair vs good, very good, or excellent), and walking for leisure in the past 7 days (in minutes).

RESULTS

Among 52 646 adult renters and other nonhomeowners, 50.3% were female, 85.2% were younger than 60 years, 45.3% were Hispanic, and 55.1% had income lower than 200% of the federal poverty level. Overall, 8.9% of renters reported making a recent cost-driven move, with higher prevalence among Hispanic (9.9%) and non-Hispanic Black (11.3%) renters compared with non-Hispanic White renters (7.2%). In multivariable models, compared with not moving, cost-driven moving was associated with a 4.2 (95% CI, 2.6-5.7) percentage point higher probability of experiencing moderate psychological distress; a 3.2 (95% CI, 1.9-4.5) percentage point higher probability of experiencing severe psychological distress; a 2.5 (95% CI, 0-4.9) percentage point higher probability of ED visits; a 5.1 (95% CI, 1.6-8.6) percentage point lower probability of having preventive care visits; a 3.7 (95% CI, 1.2-6.2) percentage point lower probability of having good, very good, or excellent general health; and 16.8 (95% CI, 6.9-26.6) fewer minutes of walking for leisure. General health, psychological distress, and walking for leisure were also worse with cost-driven moves relative to non-cost-driven moves, with a 3.2 (95% CI, 1.7-4.7) percentage point higher probability of experiencing moderate psychological distress; a 2.5 (95% CI, 1.2-3.9) percentage point higher probability of experiencing severe psychological distress; a 4.6 (95% CI, 2.1-7.2) percentage point lower probability of having good, very good, or excellent general health; and 13.0 (95% CI, 4.0-21.9) fewer minutes of walking for leisure. However, the incidence of preventive care and ED visits did not differ between those who made cost-driven vs non-cost-driven moves.

CONCLUSIONS AND RELEVANCE

In this study, cost-driven moves were associated with adverse health-related outcomes relative to not moving and to non-cost-driven moves. These findings suggest that policies to improve housing affordability, prevent displacement, and increase access to health care for groups vulnerable to cost-driven moves may have the potential to improve population health equity, especially during the current national housing affordability crisis.

Association of California Immigrants' Avoidance of Public Programs Due to Immigration Concerns With Delayed Access to Health Care

This cross-sectional study examines the association of avoidance of public programs among California immigrants with delayed access to health care services and prescriptions owing to concerns about how their interaction with these services may affect their immigration status.

Measuring Asian hate: Discordant reporting of race-based hate incidents and unfair treatment and association with measures of wellbeing

Background

During COVID-19, anti-Asian discrimination increased in attention. Hate and unfair treatment are related but do not completely overlap. We expect those who report a hate incident would also report race-based unfair treatment, yet feelings of social desirability or self-blame may lead to under-reporting of unfair treatment.

Objectives

To describe reporting of an experience of race-based hate but not an experience of race-based unfair treatment among Asians in California and explore the association between this reporting discordance with (1) serious psychological distress, (2) forgoing needed medical care, (3) increased household interpersonal conflict, and (4) feeling unsafe in their neighborhood.

Methods

We used the 2020 California Health Interview Survey's AANHPI COVID Module, conducted weighted descriptive and multivariate analyses, and computed adjusted relative risks (RR). The multivariate models controlled for Asian subgroup, age, gender, immigrant status, education level, poverty, and English proficiency.

Results

Among Asians who reported race-based hate (6.9% overall), 62.4% reported not experiencing race-based unfair treatment. Compared to Asians not reporting a hate incident, this "discordant" group was more likely to experience serious psychological distress (RR = 6.9), forgo necessary medical care (RR = 2.4), increased household interpersonal conflicts (RR = 2.7), and feel unsafe in their neighborhoods (RR = 3.0). The "concordant" group did not post significant effects for severe psychological distress nor forgoing necessary medical care.

Discussion

Most Asians reporting hate did not report race-based unfair treatment, and this group is most affected by the consequences of a hate incident. We indicate future directions for research and policy.

Surveying Hate and Its Effects During the COVID-19 Pandemic Among Asian Americans and Native Hawaiians and Pacific Islanders

Objectives. To summarize data collection on anti-Asian American and Native Hawaiian/Pacific Islander (AANHPI) experiences during COVID-19 and measure the associations of anti-AANHPI hate incidents with mental health, health access, and public safety among AANHPI adults. Methods. We cataloged COVID-19 surveys conducted in 2020 and 2021 on anti-AANHPI experiences. We then analyzed the 2020 California Health Interview Survey (CHIS) AANHPI COVID-19 module by constructing a variable of experiencing or witnessing a hate incident and estimating its associations with serious psychological distress, forgone care, and perceived neighborhood safety. Results. Estimates of being a victim of a hate incident ranged from 6% to 30%. In the CHIS, 28% of respondents experienced or witnessed a hate incident. Experiencing or witnessing a hate incident was significantly associated with serious psychological distress (adjusted odds ratio [AOR] = 5.33), forgoing care (AOR = 2.27), and not feeling safe in one's neighborhood (AOR = 2.70). Conclusions. Evidence from a multitude of data sources corroborates the toll of hate incidents suffered by AANHPIs. Findings regarding the negative effects of anti-AANHPI hate on mental health, health access, and public safety compel public and private investment to end victimization of AANHPI communities. (Am J Public Health. 2022;112(10):1446-1453. https://doi.org/10.2105/AJPH.2022.306977).

Lost on the frontline, and lost in the data: COVID-19 deaths among Filipinx healthcare workers in the United States

Background

Filipinx Americans working in healthcare are at risk for COVID-19 death but lack consistent mortality data on healthcare worker deaths. The lack of disaggregated data for Asian subgroups proliferates anti-Asian structural racism as the needs of high-risk groups are systematically undetected to merit a proper public health response. We work around this aggregated data problem by examining how the overrepresentation of Filipinxs in healthcare contributes to COVID-19 mortality among Asian American populations.

Methods

To overcome the lack of COVID-19 mortality data among Filipinx American healthcare workers, we merged data from several sources: Kanlungan website (the only known public-facing source of systematically reported mortality data on Filipinx healthcare workers nationally and globally), National Center for Health Statistics, and 2014-2018 American Community Survey. We examined county-level associations using t-tests, scatterplots, and linear regression.

Findings

A higher percentage of Filipinxs among Asian Americans was correlated with a higher percentage of COVID-19 decedents who are Asian Americans (r = 0.24, p = 0.01). The percentage of Filipinx in healthcare remained a strong predictor of COVID-19 deaths among Asian Americans even after adjusting for age, poverty, and population density (coef = 1.0, p < 0.001). For every 1% increase in Filipinx among the healthcare workforce, the percentage of Asian American COVID-19 decedents increased by 1%.

Interpretation

Our study shows that the overrepresentation of Filipinxs in healthcare contributes to COVID-19 mortality disparities among Asian Americans. Our findings advocate for systems change by practicing anti-racist data agendas that collect and report on Asian subgroups for effective real-time targeted approaches against health inequities.

Learning to love ourselves again: Organizing Filipinx/a/o scholar-activists as antiracist public health praxis

A critical component for health equity lies in the inclusion of structurally excluded voices, such as Filipina/x/o Americans (FilAms). Because filam invisibility is normalized, denaturalizing these conditions requires reimagining power relations regarding whose experiences are documented, whose perspectives are legitimized, and whose strategies are supported. in this community case study, we describe our efforts to organize a multidisciplinary, multigenerational, community-driven collaboration for FilAm community wellness. Catalyzed by the disproportionate burden of deaths among FilAm healthcare workers at the onset of the COVID-19 pandemic and the accompanying silence from mainstream public health leaders, we formed the Filipinx/a/o Community Health Association (FilCHA). FilCHA is a counterspace where students, faculty, clinicians, and community leaders across the nation could collectively organize to resist our erasure. By building a virtual, intellectual community that centers our voices, FilCHA shifts power through partnerships in which people who directly experience the conditions that cause inequities have leadership roles and avenues to share their perspectives. We used Pinayism to guide our study of FilCHA, not just for the current crisis State-side, but through a multigenerational, transnational understanding of what knowledges have been taken from us and our ancestors. By naming our collective pain, building a counterspace for love of the community, and generating reflections for our communities, we work toward shared liberation. Harnessing the collective power of researchers as truth seekers and organizers as community builders in affirming spaces for holistic community wellbeing is love in action. This moment demands that we explicitly name love as essential to antiracist public health praxis.

Measuring Structural Racism: A Guide for Epidemiologists and Other Health Researchers

There have been over 100 years of literature discussing the deleterious influence of racism on health. Much of the literature describes racism as a driver of social determinants of health, such as housing, employment, income, and education. More recently, increased attention has been given to measuring the structural nature of a system that advantages one racialized group over others rather than solely relying on individual acknowledgement of racism. Despite these advances, there is still a need for methodological and analytical approaches to complement the aforementioned. This commentary calls on epidemiologists and other health researchers at large to engage the discourse on measuring structural racism. First, we address the conflation between race and racism in epidemiologic research. Next, we offer methodological recommendations (linking of interdisciplinary variables and data sets and leveraging mixed-method and life-course approaches) and analytical recommendations (integration of mixed data, use of multidimensional models) that epidemiologists and other health researchers may consider in health equity research. The goal of this commentary is to inspire the use of up-to-date and theoretically driven approaches to increase discourse among public health researchers on capturing racism as well as to improve evidence of its role as the fundamental cause of racial health inequities.

Addressing The Interlocking Impact Of Colonialism And Racism On Filipinx/a/o American Health Inequities

Within the monolithic racial category of "Asian American," health determinants are often hidden within each subgroup's complex histories of indigeneity, colonialism, migration, culture, and socio-political systems. Although racism is typically framed to underscore the ways in which various institutions (for example, employment and education) disproportionately disadvantage Black/Latinx communities over White people, what does structural racism look like among Filipinx/a/o Americans (FilAms), the third-largest Asian American group in the US? We argue that racism defines who is visible. We discuss pathways through which colonialism and racism preserve inequities for FilAms, a large and overlooked Asian American subgroup. We bring to light historical and modern practices inhibiting progress toward dismantling systemic racial barriers that impinge on FilAm health. We encourage multilevel strategies that focus on and invest in FilAms, such as robust accounting of demographic data in heterogeneous populations, explicitly naming neocolonial forces that devalue and neglect FilAms, and structurally supporting community approaches to promote better self- and community care.

Life Satisfaction and Social and Emotional Support Among Asian American Older Adults

BACKGROUND

Little data exist on the well-being of older adults from Asian American (AA) communities.

METHODS

Using data from the 2018 California Health Interview Survey, we examined 2 well-being metrics among AAs and AA subgroups (Korean, Filipino, Vietnamese, Chinese) 65 years and older.

RESULTS

AA older adults reported lower life satisfaction and not having needed social and emotional support compared with all other race/ethnicities. Current life satisfaction among AA older adults was 54% compared with 80% for all other race/ethnicities; 56% of AA older adults reported usually or always receiving social/emotional compared with 80% for all other race/ethnicities. Within the AA category, life satisfaction was 40% for Korean, 48% for Chinese, 47% for Vietnamese, and 77% for Filipino older adults. Among Korean older adults, 30% reported receiving needed social/emotional support, 57% among Chinese, 59% among Filipino, and 65% among Vietnamese older adults.

CONCLUSION

AA older adults report lower life satisfaction and not needed receiving social and emotional support compared with all other race/ethnicities. Among AAs, Korean older adults were most likely to report poorer well-being. AA older adult communities may be in urgent need of further research and investment in interventions.

The relationship between educational attainment and hospitalizations among middle-aged and older adults in the United States

BACKGROUND

There has been little research on the relationship between education and healthcare utilization, especially for racial/ethnic minorities. This study aimed to examine the association between education and hospitalizations, investigate the mechanisms, and disaggregate the relationship by gender, race/ethnicity, and age groups.

METHODS

A retrospective cohort analysis was conducted using data from the 1992-2016 US Health and Retirement Study. The analytic sample consists of 35,451 respondents with 215,724 person-year observations. We employed a linear probability model with standard errors clustered at the respondent level and accounted for attrition bias using an inverse probability weighting approach.

RESULTS

On average, compared to having an education less than high school, having a college degree or above was significantly associated with an 8.37 pp (95% CI, -9.79 pp to -7.95 pp) lower probability of being hospitalized, and having education of high school or some college was related to 3.35 pp (95% CI, -4.57 pp to -2.14 pp) lower probability. The association slightly attenuated after controlling for income but dramatically reduced once holding health conditions constant. Specifically, given the same health status and childhood environment conditions, compared to those with less than high school degree, college graduates saw a 1.79 pp (95% CI, -3.16 pp to -0.42 pp) lower chance of being hospitalized, but the association for high school graduates became indistinguishable from zero. Additionally, the association was larger for females, whites, and those younger than 78. The association was statistically significantly smaller for black college graduates than their white counterparts, even when health status is held constant.

CONCLUSIONS

Educational attainment is a strong predictor of hospitalizations for middle-aged and older US adults. Health mediates most of the education-hospitalization gradients. The heterogeneous results across age, gender, race, and ethnicity groups should inform further research on health disparities.

Disparities in Native Hawaiian and Pacific Islander COVID-19 Mortality: A Community-Driven Data Response

As of March 2021, Native Hawaiians and Pacific Islanders (NHPIs) in the United States have lost more than 800 lives to COVID-19-the highest per capita death rate in 18 of 20 US states reporting NHPI deaths. However, NHPI risks are overlooked in policy discussions. We discuss the NHPI COVID-19 Data Policy Lab and dashboard, featuring the disproportionate COVID-19 mortality burden for NHPIs. The Lab democratized NHPI data, developed community infrastructure and resources, and informed testing site and outreach policies related to health equity.

Housing Insecurity Among Latinxs

Latinxs are vulnerable to experiencing housing insecurity and less likely to receive public benefits, such as health insurance, which can impact a household's economic resources. We inform homelessness prevention by examining the association of social risks and healthcare access with housing insecurity for Latinxs. Our sample consisted of 120,362 participants under the age of 65, of which 17.3% were Latinx. Weighted chi-squared tests and logistic regression were used to examine predictors of housing insecurity. Housing insecurity was measured as worry about paying for housing. Latinxs were almost twice as likely as non-Latinxs to worry about paying for housing. Excellent/fair health status, health service use, and having health insurance decreased the likelihood of housing insecurity for Latinxs. Access to health insurance, regardless of citizenship status, and use of preventative healthcare to maintain good health can be protective against housing insecurity.

A Rapid Assessment of the Impact of COVID-19 on Asian Americans: Cross-sectional Survey Study

BACKGROUND

The diverse Asian American population has been impacted by the COVID-19 pandemic, but due to limited data and other factors, disparities experienced by this population are hidden.

OBJECTIVE

This study aims to describe the Asian American community's experiences during the COVID-19 pandemic, focusing on the Greater San Francisco Bay Area, California, and to better inform a Federally Qualified Health Center's (FQHC) health care services and response to challenges faced by the community.

METHODS

We conducted a cross-sectional survey between May 20 and June 23, 2020, using a multipronged recruitment approach, including word-of-mouth, FQHC patient appointments, and social media posts. The survey was self-administered online or administered over the phone by FQHC staff in English, Cantonese, Mandarin, and Vietnamese. Survey question topics included COVID-19 testing and preventative behaviors, economic impacts of COVID-19, experience with perceived mistreatment due to their race/ethnicity, and mental health challenges.

RESULTS

Among 1297 Asian American respondents, only 3.1% (39/1273) had previously been tested for COVID-19, and 46.6% (392/841) stated that they could not find a place to get tested. In addition, about two-thirds of respondents (477/707) reported feeling stressed, and 22.6% (160/707) reported feeling depressed. Furthermore, 5.6% (72/1275) of respondents reported being treated unfairly because of their race/ethnicity. Among respondents who experienced economic impacts from COVID-19, 32.2% (246/763) had lost their regular jobs and 22.5% (172/763) had reduced hours or reduced income. Additionally, 70.1% (890/1269) of respondents shared that they avoid leaving their home to go to public places (eg, grocery stores, church, and school).

CONCLUSIONS

We found that Asian Americans had lower levels of COVID-19 testing and limited access to testing, a high prevalence of mental health issues and economic impacts, and a high prevalence of risk-avoidant behaviors (eg, not leaving the house) in the early months of the COVID-19 pandemic. These findings provide preliminary insights into the impact of the COVID-19 pandemic on Asian American communities served by an FQHC and underscore the longstanding need for culturally and linguistically appropriate approaches to providing mental health, outreach, and education services. These findings led to the establishment of the first Asian multilingual and multicultural COVID-19 testing sites in the local area where the study was conducted, and laid the groundwork for subsequent COVID-19 programs, specifically contact tracing and vaccination programs.

Booms and Busts in Housing Market and Health Outcomes for Older Americans

Background and Objectives

The US housing market has experienced considerable fluctuations over the last decades. This study aimed to investigate the impacts of housing price dynamics on physical health, mental health, and health-related behaviors for older American outright owners, mortgaged owners, and renters.

Research Design and Methods

We drew longitudinal data from the 1992–2016 Health and Retirement Study and merged it to the 5-digit zip code–level Housing Price Index. The analytic sample comprised 34 182 persons and 174 759 person-year observations. We used a fixed-effects model to identify the health impacts of housing price dynamics separately for outright owners, mortgaged owners, and renters.

Results

A 100% increase in Housing Price Index was associated with a 2.81 and 3.50 percentage points (pp) increase in the probability of reporting excellent/very good/good health status for mortgage owners and renters, respectively. It was also related to a lower likelihood of obesity (1.82 pp) for outright owners and a lesser chance of obesity (2.85 pp) and smoking (3.03 pp) for renters. All of these relationships were statistically significant (p < .05). Renters also experienced significantly decreased depression scores (−0.24), measured by the Center for Epidemiologic Studies—Depression scale, associated with the same housing price changes.

Discussion and Implications

Housing price dynamics have significant health impacts, and renters are more sensitive to fluctuations in the housing market. Our study rules out the wealth effect as the mechanism through which changes in housing prices affect older adults’ health. Our findings may inform policies to promote older adults’ health by investing in local area amenities and improving socioeconomic conditions.

Asian, Latinx, or Multiracial? Assessing Filipinxs' Health Conditions and Outcomes by Aggregate Ethnic Category

INTRODUCTION

Filipinxs are the second-largest Asian subgroup in the USA. While Filipinxs are most often considered Asian when constructing aggregate ethnic categories, recent research has identified a trend of a small portion of Filipinxs identifying as Latinx or multiracial. However, little research had addressed how identification with different aggregate ethnic categories may have implications for identifying health disparities among Filipinxs and how these compare to non-Hispanic whites.

METHODS

Bivariate and multivariable regression analyses using 2011-2018 California Health Interview Survey data, comparing Asian Filipinxs, Latinx Filipinxs, and multiracial Filipinxs.

RESULTS

In bivariate analyses, Asian Filipinxs had a higher prevalence of diabetes than Latinx or multiracial Filipinxs. After controlling for sociodemographics, Latinx Filipinxs had significantly lower odds of having diabetes or heart disease than Asian Filipinxs. Compared to non-Latinx Whites, Asian Filipinxs reported higher odds of being in fair/poor health, obese or overweight, high blood pressure, and diabetes, multiracial Filipinxs reported higher odds of being obese or overweight, and Latinx Filipinxs reported lower odds of heart disease.

DISCUSSION

These findings suggest emerging differences in health linked to identification with different ethnic categories, underscoring the need to investigate nuances among Filipinxs in future research as well as highlighting the utility of emerging sociological insights in health research.

The Association Between Moderate and Serious Mental Health Distress and General Health Services Utilization Among Chinese, Filipino, Japanese, Korean, and Vietnamese Adults in California

INTRODUCTION

A growing body of literature has indicated that disaggregated analyses using distinct Asian subgroups allow for identification of varying mental health challenges and health services utilization. In this study, we examined the associations between distress and health services utilization among five Asian subgroups: Chinese, Korean, Japanese, Filipino, and Vietnamese adults in California.

MATERIALS AND METHODS

Using a combined dataset using the 2011-2018 cross-sectional cycles of the California Health Interview survey, we assessed moderate and serious distress and four health services utilization indicators in a set of disaggregated analyses among adults 18 years of age and older in five Asian subgroups. We performed bivariate and multivariable analyses.

RESULTS

The prevalence of and associations between moderate and serious distress and gaps in health services utilization varied among each Asian subgroup. Koreans had the highest prevalence of moderate and serious distress and the most gaps in health services utilization. Compared to those without moderate distress (p < .05), Japanese adults were more likely to delay care. Compared to those without serious distress (p < .05), Chinese adults who experienced serious distress were more likely to delay both medications and care, whereas Filipino and Vietnamese adults were more likely to delay medications.

DISCUSSION

Disaggregating health data elucidates the impact of mental distress on healthcare-seeking behaviors among specific Asian subgroups. Identifying these influences can facilitate future tailored interventions, yet fully understanding the mechanism linking mental distress and healthcare usage will necessitate a comprehensive assessment of structural influences and Asian American experiences without otherization.

Enabling Services Improve Access To Care, Preventive Services, And Satisfaction Among Health Center Patients

Enabling services address a combination of social determinants of health and barriers to access to primary care and are intended to reduce health disparities. They include care coordination; health education; transportation; and assistance with obtaining food, shelter, and benefits. Empirical evidence of enabling services' potential contribution to health outcomes is limited, which impedes their widespread dissemination. We examined how the receipt of enabling services influenced patient health care outcomes based on a nationally representative survey of patients served in 2014 at health centers funded by the Health Resources and Services Administration. We compared enabling services users and nonusers and found that enabling services were associated with 1.92 more health center visits, an 11.78-percentage-point higher probability of getting a routine checkup, a 16.34-percentage-point higher likelihood of having had a flu shot, and a 7.63-percentage-point higher probability of patient satisfaction. Our results confirm the value of systematic delivery of enabling services in reducing access barriers and improving patient satisfaction.

Worse Mental Health Among More-Acculturated and Younger Immigrants Experiencing Discrimination: California Health Interview Survey, 2015-2016

BACKGROUND

Experiences of discrimination harm mental and physical health, with the strongest penalty on mental health. Among immigrants, it remains unclear how acculturation-the process by which immigrants acquire the beliefs and practices of a host culture-influences the mental health burden of navigating discrimination. On the one hand, acculturation can be associated with upward social mobility. Conversely, the acculturative process may increase exposure to, and recognition of, discrimination.

OBJECTIVES

We examined the relationship between discrimination and mental illness across racial/ethnic groups, and pathways by which acculturation and age relate to the discrimination-mental health relationship.

DESIGN

A secondary data analysis using population data from the 2015-2016 California Health Interview Survey.

MAIN MEASURES

The Kessler 6-item Psychological Distress Scale (K6) assessed symptoms of psychological distress, with K6 score ≥ 13 associated with severe mental illness. Discrimination was measured using a self-reported measure of lifetime experience of unfair treatment in getting medical care. We used a 5-point acculturation index (constructed by measures of nativity, years living in the USA, and home language use). A weighted logistic regression model predicted mental illness as a function of discrimination. We ran mediational analysis using the Karlson-Holm-Breen method and used predictive margins to present predicted probabilities of mental illness for people reporting discrimination at different acculturation and age levels.

KEY RESULTS

There were independent effects on mental illness associated with increased discrimination (OR 3.85, 95% CI = 2.46, 6.03, p < 0.001) and increased acculturation (OR 1.72, 95% CI = 1.24, 2.38, p = 0.001), including when stratified across racial/ethnic groups. Higher levels of acculturation led to a significant increase in discrimination's association with mental illness. There was a higher probability of mental illness in younger age groups than in older age groups.

CONCLUSIONS

While discrimination is associated with poor mental health, a stronger link between discrimination and mental illness exists among younger immigrants and immigrants with increased acculturation. Health practitioners should not overlook the mental health needs of younger immigrants and immigrants who may seem more integrated into US society.

Health Conditions, Outcomes, and Service Access Among Filipino, Vietnamese, Chinese, Japanese, and Korean Adults in California, 2011-2017

Objectives. To determine the impact of data disaggregation on the ability to identify health disparities and needs for future research for Filipino, Vietnamese, Chinese, Japanese, and Korean adults in California.Methods. Using available data from the 2011-2017 California Health Interview Survey, we conducted bivariate and multivariable analyses to assess disparities in health conditions, outcomes, and service access compared with non-Hispanic Whites for Asians as an overall group and for each individual subgroup.Results. As an aggregate category, Asians appeared healthier than did non-Hispanic Whites on most indicators. However, every Asian subgroup had at least 1 disparity disguised by aggregation. Filipinos had the most disparities, with higher prevalence of fair or poor health, being obese or overweight, and having high blood pressure, diabetes, or asthma compared with non-Hispanic Whites (P < .05) in multivariable analyses.Conclusions. Failure to disaggregate health data for individual Asian subgroups disguises disparities and leads to inaccurate conclusions about needs for interventions and research.

Impact of gentrification on adult mental health

OBJECTIVE

To estimate the net effect of living in a gentrified neighborhood on probability of having serious psychological distress.

DATA SOURCES

We pooled 5 years of secondary data from the California Health Interview Survey (2011-2015) and focused on southern California residents.

STUDY DESIGN

We compared adults (n = 43 815) living in low-income and gentrified, low-income and not gentrified, middle- to high-income and upscaled, and middle- to high-income and not upscaled neighborhoods. We performed a probit regression to test whether living in a gentrified neighborhood increased residents' probabilities of having serious psychological distress in the past year and stratified analyses by neighborhood tenure, homeownership status, and low-income status. Instrumental variables estimation and propensity scores were applied to reduce bias arising from residential selection and simultaneity. An endogenous treatment effects model was also applied in sensitivity analyses.

DATA COLLECTION/EXTRACTION METHODS

Adults who completed the survey on their own and lived in urban neighborhoods with 500 or more residents were selected for analyses. Survey respondents who scored 13 and above on the Kessler 6 were categorized as having serious psychological distress in the past year. We used eight neighborhood change measures to classify respondents' neighborhoods.

PRINCIPAL FINDINGS

Living in a gentrified and upscaled neighborhood was associated with increased likelihood of serious psychological distress relative to living in a low-income and not gentrified neighborhood. The average treatment effect was 0.0141 (standard error = 0.007), which indicates that the prevalence of serious psychological distress would have been 1.4 percentage points less if none of the respondents lived in gentrified neighborhoods. Gentrification appears to have a negative impact on the mental health of renters, low-income residents, and long-term residents. This effect was not observed among homeowners, higher-income residents, and recent residents.

CONCLUSIONS

Gentrification levies mental health costs on financially vulnerable community members and can worsen mental health inequities.

Ambulance diversions following public hospital emergency department closures

OBJECTIVE

To examine whether hospitals are more likely to temporarily close their emergency departments (EDs) to ambulances (through ambulance diversions) if neighboring diverting hospitals are public vs private.

DATA SOURCES/STUDY SETTING

Ambulance diversion logs for California hospitals, discharge data, and hospital characteristics data from California's Office of Statewide Health Planning and Development and the American Hospital Association (2007).

STUDY DESIGN

We match public and private (nonprofit or for-profit) hospitals by distance and size. We use random-effects models examining diversion probability and timing of private hospitals following diversions by neighboring public vs matched private hospitals.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Hospitals are 3.6 percent more likely to declare diversions if neighboring diverting hospitals are public vs private (P < 0.001). Hospitals declaring diversions have lower ED occupancy (P < 0.001) after neighboring public (vs private) hospitals divert. Hospitals have 4.2 percent shorter diversions if neighboring diverting hospitals are public vs private (P < 0.001). When the neighboring hospital ends its diversion first, hospitals terminate diversions 4.2 percent sooner if the neighboring hospital is public vs private (P = 0.022).

CONCLUSIONS

Sample hospitals respond differently to diversions by neighboring public (vs private) hospitals, suggesting that these hospitals might be strategically declaring ambulance diversions to avoid treating low-paying patients served by public hospitals.

Promoting Health Equity And Eliminating Disparities Through Performance Measurement And Payment

Current approaches to health care quality have failed to reduce health care disparities. Despite dramatic increases in the use of quality measurement and associated payment policies, there has been no notable implementation of measurement strategies to reduce health disparities. The National Quality Forum developed a road map to demonstrate how measurement and associated policies can contribute to eliminating disparities and promote health equity. Specifically, the road map presents a four-part strategy whose components are identifying and prioritizing areas to reduce health disparities, implementing evidence-based interventions to reduce disparities, investing in the development and use of health equity performance measures, and incentivizing the reduction of health disparities and achievement of health equity. To demonstrate how the road map can be applied, we present an example of how measurement and value-based payment can be used to reduce racial disparities in hypertension among African Americans.

Managing Diversity To Eliminate Disparities: A Framework For Health

By 2044 there will be no single racial or ethnic majority group in the US, according to the Census Bureau. California experienced this shift in 2000, making the state a bellwether in its attempts to bring health equity to a highly diverse population. We used data from the California Health Interview Survey and the California Regional Health Care Cost and Quality Atlas to examine health, health care access, and quality of care by race/ethnicity, payer, and region. Evaluating insurance coverage and diabetes as a sentinel condition, we found that wealthy regions exhibited the widest disparities-with advantages among non-Latino whites and people with commercial coverage. Disparities were narrowest in rural and agricultural regions, but health and quality of care were lower overall in those regions. State initiatives to address health equity include requiring health plans to reduce disparities by language and race/ethnicity and investing carbon cap-and-trade revenues in disadvantaged communities. Prominent advocacy, community engagement, the systematic use of data, local flexibility, and mechanisms for stronger accountability are driving these initiatives. Evidence has yet to emerge on how effective these policies will be in reducing health disparities in the state.

The impact of rising food prices on obesity in women: a longitudinal analysis of 31 low-income and middle-income countries from 2000 to 2014

OBJECTIVES

To examine whether changes in food prices are associated with changes in obesity prevalence among women in developing countries, and assess effect modification by individual socioeconomic status (SES).

METHODS

Longitudinal study of country-level food price inflation temporally and geographically linked to anthropometric data on non-pregnant adult women (n = 295,984) in 31 low-income and middle-income countries over the 2000-2014 time period, using separate multivariable multilevel growth models of five SES indicators. Post-estimation analysis computed the relationship between food price inflation and predicted mean probabilities of being obese, by SES.

RESULTS

Rising food price inflation was strongly associated with women's obesity prevalence, and SES consistently modified the relationship. Regardless of indicator used, higher food price inflation was positively associated with obesity among women in top SES categories, but was flat or negative among women in low SES categories, averaging over time. The SES differences were widest across educational strata and were most pronounced when food price inflation was highest. Overall, for every 1-unit increase in food price inflation, predicted mean obesity prevalence was between 0.02 and 0.06 percentage points greater in women of high SES compared to low SES women.

CONCLUSION

There is a strong link between food price inflation and obesity in adult women in developing countries which is clearly modified by individuals' SES. Greater food price inflation was associated with greater obesity prevalence only among women in higher SES groups, who may be net food buyers most at risk of obesity in low-income and middle-income countries.

Perceived Need for Mental Health Care: The Intersection of Race, Ethnicity, Gender, and Socioeconomic Status

Racial/ethnic minority populations underutilize mental health services, even in the presence of psychiatric disorder, and differences in perceived need may contribute to these disparities. Using the Collaborative Psychiatric Epidemiology Surveys, we assessed how the intersections of race/ethnicity, gender, and socioeconomic status affect perceived need. We analyzed a nationally representative sample of U.S. adults (18 years or older; N=14,906), including non-Latino whites, Asian Americans, Latinos, African Americans, and Afro-Caribbeans. Logistic regressions were estimated for the total sample, a clinical need subsample (meets lifetime diagnostic criteria), and a no disorder subsample. Perceived need varies by gender and nativity, but these patterns are conditional on race/ethnicity. Men are less likely than women to have a perceived need but only among non-Latino whites and African Americans. Foreign-born immigrants have lower perceived need than U.S.-born persons, only among Asian Americans. Intersectional approaches to understanding perceived need may help uncover social processes that lead to disparities in mental health care.

Racial/Ethnic Differential Effects of Medicaid Expansion on Health Care Access

OBJECTIVE

To assess racial/ethnic differential impacts of the ACA's Medicaid expansion on low-income, nonelderly adults' access to primary care.

DATA SOURCES

Behavioral Risk Factor Surveillance System, State Physicians Workforce Data Book, and Bureau of Labor Statistics, in 2013 and 2015.

STUDY DESIGN

Quasi-experimental design with difference-in-differences analyses. Outcomes included health insurance coverage, having personal doctor(s), being unable to see doctors because of cost, and receiving a flu shot. We tested racial/ethnic differential impacts using the "Seemingly unrelated estimation" method. Multiple imputations and survey weights were used.

DATA COLLECTION/EXTRACTION METHODS

Low-income, nonelderly adults were identified based on age, household income, and family size.

PRINCIPAL FINDINGS

Among the low-income, nonelderly adults, Medicaid expansion was associated with statistically significant gains in health insurance coverage, having personal doctors, and affordability. Hispanics got the fewest benefits, which significantly widened racial/ethnic disparities for the Hispanic group. Racial/ethnic disparity in having personal doctors narrowed for non-Hispanic black and non-Hispanic others, although not statistically significant.

CONCLUSION

Medicaid expansion improved access to primary care, but it had differential effects among racial/ethnic groups resulting in mixed effects on disparities. Further research is necessary to develop tailored policy tools for racial/ethnic groups.

The effect of household poverty on tuberculosis

pSETTING: Households in Malawi, Mongolia, Myanmar, the Philippines, Rwanda, Tanzania, Viet Nam and Zambia.OBJECTIVE To assess the relationship between household socio-economic level, both relative and absolute, and individual tuberculosis (TB) disease.

DESIGN

We analysed national TB prevalence surveys from eight countries individually and in pooled multicountry models. Socio-economic level (SEL) was measured in terms of both relative household position and absolute wealth. The outcome of interest was whether or not an individual had TB disease. Logistic regression models were used to control for putative risk factors for TB disease such as age, sex and previous treatment history.

RESULTS

Overall, a strong and consistent association between household SEL and individual TB disease was not found. Significant results were found in four individual country models, with the lowest socio-economic quintile being associated with higher TB risk in Mongolia, Myanmar, Tanzania and Viet Nam.

CONCLUSIONS

TB prevalence surveys are designed to assess prevalence of disease and, due to the small numbers of cases usually detected, may not be the most efficient means of investigating TB risk factors. Different designs are needed, including measuring the SEL of individuals in nested case-control studies within TB prevalence surveys or among TB patients seeking treatment in health care facilities.

Helpfulness, Trust, and Safety of Neighborhoods: Social Capital, Household Income, and Self-Reported Health of Older Adults

Background and Objectives

Growing literature documents that where you live has an impact on your health, due in part to social capital. Building on social capital literature, we assess how subjective appraisals of neighborhood quality are associated with self-reported health (SRH) for older adults.

Research Design and Methods

Cross-sectional analysis of the 2014 California Health Interview Survey, a representative survey of diverse, noninstitutionalized California residents. We use three measures of neighborhood quality: trustworthy neighbors, helpful neighbors, and feeling safe. Using weighted ordinary least squares regression, we assess the associations of trust, helpfulness, and safety to SRH, controlling for neighborhood, demographic, and health care variables. We then examine how these associations vary by household income.

Results

We find that characterizing neighbors as helpful and feeling safe are associated with better SRH, even controlling for community, demographic, and health care variables. However, the importance of these dimensions varies across household income: helpfulness is positively associated, whereas trust is negatively associated with SRH for lower income residents; safety is positively associated with SRH in all but the lowest income residents. These findings show that social capital dimensions work differently from one another, and differentially affect the health of older adults.

Discussion and Implications

Scholarly analyses of neighborhood effects should include a range of social capital measures and stratify by household income. Our findings may also inform priority setting for social capital programs, especially for older adults with limited economic resources. Policies and programs should consider actions that raise perceptions of helpfulness and safety.

Complying with the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and solutions

The Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare-participating hospitals to provide emergency care to patients regardless of their ability to pay, plays an important role in protecting the uninsured. Yet many hospitals do not comply. This study examines the reasons for noncompliance and proposes solutions. We conducted 11 semistructured key informant interviews with hospitals, hospital associations, and patient safety organizations in the Centers for Medicare and Medicaid Services region with the highest number of EMTALA complaints filed. Respondents identified 5 main causes of noncompliance: financial incentives to avoid unprofitable patients, ignorance of EMTALA's requirements, high referral burden at hospitals receiving EMTALA transfer patients, reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations, and opposing priorities of hospitals and physicians. Respondents suggested 5 methods to improve compliance, including educating subspecialists about EMTALA, informally educating hospitals about borderline violations, and incorporating EMTALA-compliant processes into hospital operations such as by routing transfer requests through the emergency department. To improve compliance we suggest (1) more closely aligning Medicaid/Medicare payment policies with EMTALA, (2) amending the Act to permit informal mediation between hospitals about borderline violations, (3) increasing the hospital's role in ensuring EMTALA compliance, and (4) expanding the role of hospital associations.

The former Yugoslav Republic of Macedonia: Health System Review

This analysis of the health system of the former Yugoslav Republic of Macedonia reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The country has made important progress during its transition from a socialist system to a market-based system, particularly in reforming the organization, financing and delivery of health care and establishing a mix of private and public providers. Though total health care expenditure has risen in absolute terms in recent decades, it has consistently fallen as share of GDP, and high levels of private health expenditure remain. Despite this, the health of the population has improved over the last decades, with life expectancy and mortality rates for both adults and children reaching similar levels to those in ex-communist EU countries, though death rates caused by unhealthy behaviour remain high. Inheriting a large health infrastructure, good public health services and well-distributed health service coverage after independence in 1991, the country re-built a social health insurance system with a broad benefit package. Primary care providers were privatized and new private hospitals were allowed to enter the market. In recent years, the country reformed the organization of care delivery to better incorporate both public and private providers in an integrated system. Significant efficiency gains were reached with a pioneering health information system that has reduced waiting times and led to a better coordination of care. This multi-modular e-health system has the potential to further reduce existing inefficiencies and to generate evidence for assessment and research. Despite this progress, satisfaction with health care delivery is very mixed with low satisfaction levels with public providers. The public hospital sector in particular is characterized by inefficient organization, financing and provision of health care; and many professionals move to other countries and to the private sector. Future challenges include sustainable planning and management of human resources as well as enhancing quality and efficiency of care through reform of hospital financing and organization.

Relationships Among Student, Staff, and Administrative Measures of School Climate and Student Health and Academic Outcomes

BACKGROUND

School climate is an integral part of a comprehensive approach to improving the well-being of students; however, little is known about the relationships between its different domains and measures. We examined the relationships between student, staff, and administrative measures of school climate to understand the extent to which they were related to each other and student outcomes.

METHODS

The sample included 33,572 secondary school students from 121 schools in Los Angeles County during the 2014-2015 academic year. A multilevel regression model was constructed to examine the association between the domains and measures of school climate and 5 outcomes of student well-being: depressive symptoms or suicidal ideation, tobacco use, alcohol use, marijuana use, and grades.

RESULTS

Student, staff, and administrative measures of school climate were weakly correlated. Strong associations were found between student outcomes and student reports of engagement and safety, while school staff reports and administrative measures of school climate showed limited associations with student outcomes.

CONCLUSIONS

As schools seek to measure and implement interventions aimed at improving school climate, consideration should be given to grounding these efforts in a multidimensional conceptualization of climate that values student perspectives and includes elements of both engagement and safety.

Racial/Ethnic Differences in the Impact of Neighborhood Social and Built Environment on Breast Cancer Risk: The Neighborhoods and Breast Cancer Study

Background: Neighborhood socioeconomic status (nSES) has been found to be associated with breast cancer risk. It remains unclear whether this association applies across racial/ethnic groups independent of individual-level factors and is attributable to other neighborhood characteristics.Methods: We examined the independent and joint associations of education and nSES with odds of breast cancer. Residential addresses were geocoded for 2,838 cases and 3,117 controls and linked to nSES and social and built environment characteristics. We estimated ORs and 95% confidence intervals (CI) using multilevel logistic regression controlling for individual-level breast cancer risk factors and assessed the extent to which nSES associations were due to neighborhood characteristics.Results: Women living in the highest versus lowest nSES quintile had a nearly 2-fold greater odds of breast cancer, with elevated odds (adjusted ORs, 95% CI) for non-Hispanic whites (NHWs; 2.27; 1.45-3.56), African Americans (1.74; 1.07-2.83), U.S.-born Hispanics (1.82; 1.19-2.79), and foreign-born Hispanics (1.83; 1.06-3.17). Considering education and nSES jointly, ORs were increased for low education/high nSES NHWs (1.83; 1.14-2.95), high education/high nSES NHWs (1.64; 1.06-2.54), and high education/high nSES foreign-born Hispanics (2.17; 1.52-3.09) relative to their race/ethnicity/nativity-specific low education/low nSES counterparts. Adjustment for urban and mixed-land use characteristics attenuated the nSES associations for most racial/ethnic/nativity groups except NHWs.Conclusions: Our study provides empirical evidence for a role of neighborhood environments in breast cancer risk, specifically social and built environment attributes.Impact: Considering the role of neighborhood characteristics among diverse populations may offer insights to understand racial/ethnic disparities in breast cancer risk. Cancer Epidemiol Biomarkers Prev; 26(4); 541-52. ©2017 AACR.

Who Gets Needed Mental Health Care? Use of Mental Health Services among Adults with Mental Health Need in California

Background and Purpose. Timely and appropriate treatment could help reduce the burden of mental illness. This study describes mental health services use among Californians with mental health need, highlights underserved populations, and discusses policy opportunities. Methods. Four years of California Health Interview Survey data (2011, 2012, 2013, 2014) were pooled and weighted to the 2013 population to estimate mental health need and unmet need (n=82,706). Adults with mental health need had “unmet need” if they did not use prescription medication and did not have at least four or more mental health visits in the past year. Multivariable logistic regression analysis was performed to predict the probability adults with mental health need did not receive past-year treatment (n=5,315). Results. Seventy-seven percent of Californians with mental health need received no or inadequate mental health treatment in 2013. Men, Latinos, Asians, young people, older adults, people with less education, uninsured adults, and individuals with limited English proficiency were significantly more likely to have unmet need. Cost of treatment and mental health stigma were common reasons for lack of care. Conclusion. Unmet mental health need is predominant in California. Policy recommendations include continued expansion of mental health coverage, early identification, and ensuring that treatment is culturally and linguistically appropriate.

Who Gets Needed Mental Health Care? Use of Mental Health Services among Adults with Mental Health Need in California

BACKGROUND

Timely and appropriate treatment could help reduce the burden of mental illness.

PURPOSE

This study describes mental health services use among Californians with mental health need, highlights underserved populations, and discusses policy opportunities.

METHODS

Four years of California Health Interview Survey data (2011, 2012, 2013, 2014) were pooled and weighted to the 2013 population to estimate mental health need and unmet need (n=82,706). Adults with mental health need had "unmet need" if they did not use prescription medication and did not have at least four or more mental health visits in the past year. Multivariable logistic regression analysis was performed to predict the probability adults with mental health need did not receive past-year treatment (n=5,315).

RESULTS

Seventy-seven percent of Californians with mental health need received no or inadequate mental health treatment in 2013. Men, Latinos, Asians, young people, older adults, people with less education, uninsured adults, and individuals with limited English proficiency were significantly more likely to have unmet need. Cost of treatment and mental health stigma were common reasons for lack of care.

CONCLUSION

Unmet mental health need is predominant in California. Policy recommendations include continued expansion of mental health coverage, early identification, and ensuring that treatment is culturally and linguistically appropriate.

Medicare Payment Policy Creates Incentives For Long-Term Care Hospitals To Time Discharges For Maximum Reimbursement

Long-term care hospitals are postacute care facilities for patients requiring extended hospital-level care. These facilities are reimbursed by Medicare under a prospective payment system with a short-stay outlier policy, which results in substantially lower payments for patients discharged before a diagnosis-related group-specific short-stay threshold. Using Medicare data, we examined the impact of the short-stay policy on lengths-of-stay and Medicare reimbursement among patients in long-term care hospitals who require prolonged mechanical ventilation. After accounting for case-mix and facility-level differences, we found that discharges for reasons other than death in the period 2005-10 were most likely to occur on the day of or immediately after the short-stay threshold; this held true regardless of facility ownership. In contrast, live discharges in 2002—the year before the prospective payment system started phasing out cost-based payment—were evenly distributed around the day that later became the short-stay threshold. Our findings confirm that the short-stay outlier payment policy created a strong financial incentive for long-term care hospitals to time patient discharges to maximize Medicare reimbursement. The results suggest that the new very-short-stay policy implemented in December 2012 could have a similar effect.